<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_id" data-rule="required" data-source="presentation/index" class="form-control selectpage form-control" name="row[presentation_id]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Patient_name_or_initials')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-patient_name_or_initials" class="form-control form-control" name="row[patient_name_or_initials]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Gp_medical_record_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-gp_medical_record_number" class="form-control form-control" name="row[gp_medical_record_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Specialist_record_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-specialist_record_number" class="form-control form-control" name="row[specialist_record_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Hospital_record_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-hospital_record_number" class="form-control form-control" name="row[hospital_record_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Investigation_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-investigation_number" class="form-control form-control" name="row[investigation_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Body_weight_kg')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-body_weight_kg" class="form-control form-control" name="row[body_weight_kg]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Height_cm')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-height_cm" class="form-control form-control" name="row[height_cm]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Sex')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-sex" class="form-control selectpicker" name="row[sex]">
                {foreach name="sexList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Last_menstrual_period_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-last_menstrual_period_date" class="form-control form-control" name="row[last_menstrual_period_date]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Reaction_event')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-reaction_event" class="form-control form-control" name="row[reaction_event]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Concomitant_therapies')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-concomitant_therapies" class="form-control selectpicker" name="row[concomitant_therapies]">
                {foreach name="concomitantTherapiesList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Date_of_death')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-date_of_death" class="form-control form-control" name="row[date_of_death]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Was_autopsy_done')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-was_autopsy_done" class="form-control selectpicker" name="row[was_autopsy_done]">
                {foreach name="wasAutopsyDoneList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
